Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your health care will cost.

Under the law, health care providers need to give patients who don't have certain types of health care coverage or who are not using certain types of health care coverage, an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

PRIVACY ACT STATEMENT

CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: ( 1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entities' compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

HEALTH INSURANCE

If you are covered by private commercial insurance or a preferred provider organization (i.e., PPO) with out-of-network benefits, please present your identification card to the receptionist at the time of your appointment. The office will verify your benefits and you will be notified if your insurance can NOT be used for medical treatment at this practice. This office is not an in-network provider with any insurance company and does not participate with any HMO or managed care plans. If your insurance does not pay the entire balance or if part of the balance is paid, then the total balance owed will be considered due and payable. This office will NOT file a claim with Medicare or Medicaid , including but not limited to a Medicare or Medicaid Advantage Plan. The medical providers are out-of-network providers for all other insurance plans and you may be responsible for all or part of your balance. The practice does not participate with any third-party administrators such as Multiplan or Zelis. This office will not participate with any insurance plan that does not permit the office to balance bill the patient. Ultimately, it is the responsibility of the patient to know and understand his/her insurance benefits.

WORKER'S COMPENSATION

In order to be seen through the workers compensation system, this office must be authorized as a provider for your claim. If you are not authorized by worker's compensation on your first visit, this office will not bill the worker's compensation carrier even in the event of a retroactive authorization. In the event it is determined by the worker's compensation board that the illness or injury you were treated for is not a result of a compensable worker's compensation case, the fees for services rendered by this office will be payable by you and are considered reasonable and customary.

REJECTED CLAIMS

Except in an emergency room setting, if your insurance company rejects your claim, or if they pay less than the total bill, you are responsible for paying the balance in full. This office will NOT file claim with Medicare or Medicaid, including but not limited to a Medicare or Medicaid Advantage Plan, because the medical providers are not providers for Medicare, or any Medicare or Medicaid Advantage plans. The medical providers are out-of-network providers for all other insurance plans and you may be responsible all or part of your balance. This practice does not participate in any insurance plans and the doctors are out-of-network.